Ch 3 Drug Prescribing
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| The Process of Rational Drug Prescribing | Define the patient’s problem/Specify the therapeutic objective/Collaborate with the patient/Choose the treatment/Educate the pt/Monitor effectiveness.
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| Define the Patient’s Problem | Assess patient.
Develop working and differential diagnosis.
Use diagnostic tests to confirm.
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| Specify the Therapeutic Objective | Goal of treatment: Cure the disease?
Relieve symptoms of disease?
Replacing deficiencies (e.g., insulin)?
Long-term prevention?
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| Collaborate With the Patient | The World Health Organization recommends including patient in developing therapeutic objective of drug therapy.
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| Choose the Treatment | Use evidence-based guidelines/Individualize for each patient/Novice providers use analytic, step-by-step decision making/Experienced providers use exp & pattern recognition/Use more systematic approach with complex patients.
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| The I Can PresCribE A Drug Mnemonic | Indication - Contraindications - Precautions -
Cost/Compliance - Efficacy - Adverse effects -
Dose/Duration/Direction
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| Start Treatment | Patient usually fills prescription at pharmacy.
When writing prescription, discuss whether pt has ability to pay for prescrip
Insurance copays/Generics often less expensive
$4 retail lists
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| Educate the Patient | Poor adherence contributes to worsening disease, hospital admissions, and death.
Pt ed at the 5th or 6th gr level/Include in ed purpose of medication/Instructions for administration
Adverse drug reactions (ADRs)
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| Monitor Effectiveness | Passive monitoring: Pt is ed on expected outcome and instructed to contact provider.
Active monitoring: f/u lab tests or monitoring to measure therapeutic effectiveness
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| Drug Factors Influencing Drug Selection | Pharmacokinetic factors/Pharmacodynamic factors
Therapeutic factors/Safety /Cost (to patient and to society)/Patient factors/Provider factors
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| Pharmacokinetic Factors | Bioavailability /CYP 450 metabolism/Renal /elimination/Dose-concentration curve /Half-life
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| Therapeutic Factors | Evidence for therapeutic impact: Clinical trials/Clinical practice guidelines/Systematic reviews
Randomized controlled trials: Extrapolate with caution
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| Safety | Safety profile is taken into consideration/ varies by population: Teratogens/Liver or renal disease/Drug allergy
MedWatch report
U.S. Food and Drug Administration advisories
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| Cost | Cost to patient: High drug cost outlay by patient may decrease adherence/Ask about prescription drug coverage/Consider $4 retail pharmacy lists.
Cost to society: Thoughtful prescribing considers cost to health system.
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| Patient Factors | Previous ADRs/Health beliefs
Current drug therapy: Drug interactions/Consult PharmD regarding complex drug regimens.
Patient age/Pregnancy
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| Provider Factors | Ease of prescribing or monitoring
Formularies: Nurse practitioners need to be familiar with the formulary they are allowed to prescribe.
Personal formulary: Each provider develops a small list of drugs they are comfortable prescribing.
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| Influences on Rational Prescribing | Pharmaceutical promotion: May influence prescribing
When prescribing recom change: When guidelines change, providers may need to be coached or reeducated regarding appropriate prescribing.
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